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®
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End-of-life Planning: The Opposite of Death Panels
Preventing Unwanted, Indifferent and Unnecessary
Care
November 29, 2012
Confidential and Proprietary, ©Lumināt Corporation, 2012.
Spending Across Age Cohorts in the U.S.
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Confidential and Proprietary, ©Lumināt Corporation, 2012.
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Large Health Care Expenditures Occur
Near End-of-Life (EOL)
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• 30% of Medicare expenditures are
attributable to the 5% of beneficiaries who die
each year
• Health costs for patients in their final months
of life account for 25% of Medicare's total
spending.
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Riley GF, Lubitz JD. Long-term trends in Medicare payments in the last year of life. Health Serv Res. 2010;45(2):565-576.
Barnato Amber E, McClellan Mark B, Kagay Christopher R, Garber Alan M. Trends in inpatient treatment intensity among Medicare
beneficiaries at the end of life. Health Services research. 2004 April;39(2)
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Is It Possible that…
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As we approach end-of-life (EOL)
• Waste exists: Unnecessary care
• The waste is unwanted as defined by the
patient
• The savings achieved by eliminating the
unwanted care is nontrivial
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The Care People Want at EOL
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Patients’ priorities for quality care during
advanced illness and at the end of life include
• consistent and reliable medical information
• expert pain and symptom management
• avoiding inappropriate prolongation of the
dying process
• relieving burdens on loved ones
• being prepared for death
Frield M, Cassel C. Institute of Medicine (IOM Report). Approaching Death: Improving Care at the End of Life. Washington, DC: National Academy Press; 1997.
Steinhauser KE, Christakis NA, Clipp EC, et al. Factors considered important at the end of life by patients, family, physicians, and other care providers. JAMA.
2000;284:2476–82
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The Gap Between Desired Care and Care
Received at EOL is Large
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Most patients with serious illness said they would prefer
to die at home
• most patients (55%) died in the hospitals
• care was rarely aligned with their reported preferences
“The evidence therefore suggests that patients often
prefer a more conservative pattern of end-of-life care
than they actually receive -- and that a patient’s wishes
can be less influential than the practice patterns at the
hospital where care is delivered.” – The Dartmouth Atlas
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A Gap Between Desired Care and Care
Received at EOL is Substantial
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• Seventy percent of Californians say they would prefer to die
at home. However, of deaths in California in 2009, 32%
occurred at home, 42% in a hospital, and 18% in a nursing
home.
• Californians say the most important factors at the end of
their life are making sure their family is not burdened
financially by the costs of care (67% say this is extremely
important) and being comfortable and without pain (66%).
• Sixty percent say that making sure their family is not
burdened by tough decisions about their care is "extremely
important." However, 56% of Californians have not
communicated their end-of-life wishes to the loved one
they would want making decisions on their behalf.
http://www.chcf.org/publications/2012/02/final-chapter-death-dying#ixzz2DUfPhnZ7
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Employers are Impacted by EOL Care
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• Directly
– Retiree populations
– End-of-life management in the employed
population
• Indirectly
– Cost shifting
– End-of-life and elder care by the employed
population
Confidential and Proprietary, ©Lumināt Corporation, 2012.
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Direct and Indirect Sponsor Costs Near EOL
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• The cost of cancer treatment is typically
among the top three most costly conditions
representing, on average, 12% of total medical
expenses.
• Cancer is one of the leading causes of both
short- and long-term disability.
• More than 25% of employees are acting as
caregivers to family members who are
experiencing an illness, including cancer.
National Business Group on Health and National Comprehensive Cancer Network, 2011
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Indirect Sponsor Costs from EOL Management
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• The estimated average additional health cost
to employers is 8% more for those with
eldercare responsibilities. Excess medical costs
reached almost 11% for blue-collar caregivers
and over 18% for male caregivers.
• The 8% differential in health care for
caregiving employees is estimated
conservatively as costing U.S. employers $13.4
billion per year.
Working Care Givers and Employer Health Care Costs. New Insights and Innovations for Reducing
Health Care Costs for Employers. University of Pittsburgh Institute on Aging. Feb 2010.
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Knowing When to Stop
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“Our medical system is excellent at trying to
stave off death with eight-thousand-dollar-amonth chemotherapy, three-thousand-dollar-aday intensive care, five-thousand-dollar-an-hour
surgery. But, ultimately, death comes, and no
one is good at knowing when to stop.”
– Atul Gawande, Letting Go
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Advance Care Planning Sits at the Center
of the Triple Aim for EOL
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Population
Health
Advanced
Care
Planning
Healthcare
Expenditure
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Patient
Experience
Advance care planning is a process by
which people
• think about their values regarding
future healthcare choices
• communicate wishes and values to
their loved ones, their
representatives and their healthcare
team
• record their choices for healthcare
as guidance in the event that they
can no longer speak for themselves.
A health care (advance) directive is a
legal document that allows you to set
out written wishes for your medical
care, name a person to make sure those
wishes are carried out, or both.
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Advance Care Planning Can Work
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• Patients and with health care directives (and their families) have
greater satisfaction with their care.
– Feeling greater control
– Reduced fear and stigma
– Less family strife
• Lower costs
• Legal and certification (e.g., JCAHO) Requirements
›
›
›
›
›
›
›
›
Inform. Inform patient of right to have an ACD
Inquire. Inquire periodically whether patient has an ACD
Document. Document whether patient has an ACD
Assist. Upon request, refer patient to resources to assist with formulating an
ACD
Review and Revise. Allow patient to review and revise their ACD
Make Aware. Ensure staff are aware of patient’s ACD
Implement. Ensure ACDs are implemented in accordance with law and
hospital policy
Educate. Educate patients, staff and community regarding ACDs
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Current Advance Care Planning is Deficient
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• Difficult to produce
– Strictly defined (AD, proxy and, if appropriate, POLST),
approximately 10% of the population has an advance care plan.
– Useful advance care planning is complex and time consuming.
– Few professionals (lawyers, financial advisors, primary care
clinicians) are well-prepared to have an advance care planning
discussion.
– Advance care planning discussions are usually reserved for
people who are terminally ill or whose death is imminent, yet
research indicates that people suffering from chronic illness also
need advance care planning. Most age >65 die of disease other
than cancer.
– Less than 50 percent of the severely or terminally ill patients
studied had an advance directive in their medical record.
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Current Advance Care Planning is Deficient
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• Difficult to store, find, verify and apply at point-of-need
– Store and Locate
• Between 65 and 76 percent of physicians whose patients had an advance
directive were not aware that it existed.
• In a jar in the refrigerator? Scanned documents in the EMR? With the health
care proxy?
– Interpret
• Advance directives helped make end-of-life decisions in less than half of the
cases where a directive existed.
• Value-based directives require interpretation
• Disease-specific directives are difficult to create
• Physician orders for life sustaining treatment (POLST) are often not created
• Surrogates who were family members tended to make prediction errors of
overtreatment, even if they had reviewed or discussed the advance directive
with the patient or assisted in its development.
• Measurement: routine measurement is typically non-existent
Confidential and Proprietary, ©Lumināt Corporation, 2012.
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Luminat Mission and Vision
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®
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Vision: We envision a day when an individual’s wishes
are always understood and consistently honored at end
of life.
Mission: Lumināt offers a comprehensive solution that
allows provider organizations to enhance the
effectiveness of advance care planning to improve the
patient’s and family’s experience and as a result lower
the costs of care.
Confidential and Proprietary, ©Lumināt Corporation, 2012.
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Lumināt Solution
Lumināt
®
Your advance care planner℠
•
Increased adoption of advance care planning: Through an identification and
invitation process, increase the number of patients with an advance care plan.
•
Valid and comprehensive: The Lumināt advance care plan is a valid, certified and
thoughtfully constructed advance care plan that allows for a more peaceful and
satisfying experience for the patient and the family at end of life. It aligns the
complex health care system system around the patients’ wishes eliminating the
tendency for the health care system to provide care based based on assumptions
and standard operating procedures.
•
Highly accessible: the Lumināt Registry stores the patient’s ACP, allows the patient
to share it with their loved ones and is place for providers and their designees to
access the ACP quickly.
•
Measurable results: combining data from the registry and provider systems allows
for measurement of the ACP penetration, effectiveness and cost savings.
Confidential and Proprietary, ©Lumināt Corporation, 2012.
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Lumināt Solution Components
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®
Your advance care planner℠
Identify & Invite
Create & Align
Store & Access
Analyze & Measure
IDENTIFICATION
CREATION
REGISTRY
REPORTING
• Cohort sorting by
greatest need
• Targeted (30%)
invitation on Provider’s
behalf
• Participation open to all
patients
• Guide Patient with ACP
creation
• The Plan is
-- Comprehensive
-- Legally Valid
-- Consistent
-- Clinically appropriate
• Shared with proxies &
Providers
Confidential and Proprietary, ©Lumināt Corporation, 2012.
• HIPAA certified secure
cloud environment
• Annual reminders to
keep ACP current
• Comprehensive audit
control
• 24/7 secure access to
the latest ACP on file
• Comparative analytics
for patients with and
without ACP
• Reports on Patients with
complete ACPs by value
category
• Comparative analytics
on adoption rates,
access rates &
satisfaction with other
institutions
• Estimation of saving
opportunities in sum and
for each Patient
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Lumināt Value Proposition
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®
Your advance care planner℠
• A complete, provider oriented solution
– Less clinician time necessary to create a valid,
comprehensive advance care plan
– Satisfies certification requirements using a single
system
– Higher rates of availability and application of AD in
the clinical setting
– Greater satisfaction of the individual and the
family
– Lower costs per individual with advance care plan
Confidential and Proprietary, ©Lumināt Corporation, 2012.
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